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PLAN FILE NUMBER BUILDING IL' PERMIT Permit A plicatioIIHeavy nee NMER 1
NAME (OR NAME OF BUSINESS) JOB ADDRESS
el / f
N LINO ADDRESS .
BIDE YARD BET REAR YARD I ,
0
CITY TELEPHONE NUM`BL:RG USE ZONE MAP NUMBER VACANT BITE
IF
0� 6 C7 0 YES NO ;
NAME BUILDING AREA I LOT AREA I VARIANCE NUMBER
O ADDRESS. HEIGHT ALL r
NOTE: TO EAVE LANES LDING SETBACKS
CITY TELEPHONE NUMBER
REMARKS 1'..
NAME 1�
s
ADDRESS Encroachment Permit PERMIT NUMBER I STREET. GRADE CHECK r
Required Z
YES NO W a
p CITY TELEPHONE NUMBER METER SIZE SERVICE SIZE CLEARANCE I CHECKED BY i ..�
8 r,
STATE LICENSE NUMBER CITY LICENSE NUMBER REMARKS
i
LOT .BLACK TRACT -
rk It.
TYPE CONNECTION I VERIFIED BY - +�
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PERC. TEST PERMIT NUMBER 6. '
/D FIRE ZONE TE YPOF
�v / /O �_� CONSTRUCTION STREET IMPROVED _
❑YES ❑xo
SPECIAL INSPECTOR REQUIRED OCCUPANCY GROUP .
YEB NO I 'A
❑ ❑::
�J PLAN CHECKED BY
OI WORK TO BE DONE,
n A / NO. O► SLOGS. PQa RISLOG. TOTAL li[
BUILDING
I ION BUILDING
-
p7 .1
J BUILDING PERMIT W j'
It
NUMBER OF BTORIES 1 FEE D"y l ,
NEW DEMOLISH I PLUMBING It
ADD 3 PERMIT FEE J
HEAT & GAS LINE iN L s.
ALTER RESIDENTIAL NUMBER OF * PERMIT FEE
❑ I DWELLING DEMOLITION `.
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REPAIR NON-RESIDENTIAL UNITS 6 PERMIT FEE
PROPOSED UBE % I _j
t 4"
0 AMOUNT DUE n r+� t,. d
I hereby acknowledge that I have read this application; that the In-
formationAPPLICATION given 10 correct; and that I am APPLIC
the owner, or the duly author- ATTENTION
Ized agent of the owner. I agree to comply with city and state laws eegu- THIS PERMIT This application is not a permit until i.
lating construction; and In doing the work authorized tberobYo no person AUTHORIZES signed b the Director OP Building $
will be employed In violation of the Labor Code of the State of Washington ONLY THE � y g epeC-
relating to Workmen's Compensation Insurance, WORK NOTED tion, or his deputy; and fees are paid, and
NOTE: PERMIT LIMIT ONE YEAR receipt is aclmowledged in space provided.
I
L
I6NATU (OWNS O ) DATE 81O ED INSPECTION DIRECTOR!
a SIGNATURE +
DEPARTMENT
/1 T is S CITY OF lil� L
EDMONDS DwT 1
PLOT PLAN CHECK k APEAOVED 4
/ { ��✓ PR 0-1107 4
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